eMedicine Specialties > Gastroenterology > Colon

Inflammatory Bowel Disease: Differential Diagnoses & Workup

Author: William A Rowe, MD, Consulting Staff, Gastroenterology, Gastroenterology Associates
Contributor Information and Disclosures

Updated: Apr 28, 2008

Differential Diagnoses

Anorexia Nervosa
Food Poisoning
Appendicitis
Gastroenteritis, Bacterial
Bulimia
Gastroenteritis, Viral
Celiac Sprue
Giardiasis
Chronic Pelvic Pain
Intestinal Motility Disorders
Clostridium Difficile Colitis
Intestinal Radiation Injury
Collagenous and Lymphocytic Colitis
Irritable Bowel Syndrome
Cytomegalovirus
Lactose Intolerance
Cytomegalovirus Colitis
Perianal Abscess
Depression
Salmonellosis
Diverticulitis
Sarcoidosis
Eosinophilic Gastroenteritis
Ulcerative Colitis

Other Problems to Be Considered

C1 esterase deficiency
Intestinal tuberculosis
Estrogens
Backwash ileitis

Workup

Laboratory Studies

  • Laboratory studies are of value in assisting with the management of IBD but are of minimal help in establishing the diagnosis. Laboratory values may be used as surrogate markers for inflammation and nutritional status and to look for deficiencies of necessary vitamins and minerals. Serologic studies have been proposed to help diagnose IBD and to differentiate Crohn disease from ulcerative colitis.
    • Stool studies: Perform a stool culture (and C difficile toxin assay) on patients before making a definitive diagnosis of idiopathic IBD. Any patient hospitalized with a flare of colitis should, at a minimum, have a C difficile toxin assay performed because, commonly, pseudomembranous colitis is superimposed on ulcerative colitis.
    • Complete blood cell count: The components of the CBC count can be useful indicators of disease activity and iron or vitamin deficiency. An elevated WBC count is common in patients with active inflammatory disease and does not necessarily indicate infection. Anemia is common and may be either an anemia of chronic disease (usually normal mean corpuscular volume [MCV]) or an iron deficiency anemia (MCV is often low). Generally, the platelet count is normal, or, it may be mildly to moderately elevated if active inflammation is occurring, particularly if gastrointestinal blood loss occurs. Note that the MCV can be elevated in patients taking azathioprine (Imuran) or 6-mercaptopurine (6-MP).
    • Erythrocyte sedimentation rate: The erythrocyte sedimentation rate (ESR) is used as a surrogate marker for inflammation; an elevation above normal generally indicates the presence of an inflammatory response. For most, but not all, patients, the ESR can be used to help determine whether active IBD is present. Persons with cicatrix strictures are not expected to have an elevated ESR.
    • Nutritional markers: Blood tests can also be used to help determine nutritional status. The most commonly used marker is serum albumin; prealbumin and transferrin can also be used, although the latter is an acute phase reactant and can be falsely elevated in persons with active IBD. Hypoalbuminemia may reflect malnutrition; it can also develop because of the protein-losing enteropathy that can occur with active IBD.
    • Serum vitamin B-12: Vitamin B-12 deficiency can occur in patients with Crohn disease who have significant terminal ileum disease or in patients who have had terminal ileum resection. The standard replacement dose of vitamin B-12 is 1000 mcg subcutaneously every month.
    • Serum iron studies: Because active IBD is a source for gastrointestinal blood loss, iron deficiency is common. A microcytic hypochromic anemia suggests iron deficiency; if confirmed with serum iron/total iron-binding capacity, iron can be replaced either enterally or parenterally. For parenteral replacement, intravenous iron dextran can be used and is dosed based on the table in the package insert, with a maximum of 30 mL (1500 mg) at once.
    • Red blood cell folate: While folate deficiency is not common in persons with IBD, several concerns have been raised regarding this vitamin. Sulfasalazine (Azulfidine) is a folate reductase inhibitor and may inhibit normal uptake. Although some practitioners administer folate supplements in patients taking sulfasalazine, few data demonstrate that this is universally necessary. Folate supplements are indicated in all women who are pregnant to help prevent neural tube defects; this is particularly true for patients with IBD, and supplementation with 2 or more mg/d (rather than the usual 1 mg/d) should be considered.

Imaging Studies

  • Abdominal flat plate: For the patient with IBD, kidneys, ureter, and bladder radiography can provide a great deal of information. Evidence of obstruction can be seen. Evidence of inflammatory disease, especially involving the colon, can often be discerned, perforation can be detected, and toxic megacolon can be diagnosed. More subtle findings can include indications of osteopenia and nephrolithiasis.
  • Barium enema: This was one of the first studies that allowed characterization of the typical findings associated with IBD. Normal barium enema findings virtually exclude active ulcerative colitis, whereas abnormal findings can be diagnostic. Several terms have been used to describe abnormalities found after barium studies of the colon. These include the following: (1) a "stove-pipe" appearance, which suggests chronic colitis that has resulted in a loss of colonic haustrae; (2) "rectal sparing," which suggests Crohn colitis in the presence of inflammatory changes in other portions of the colon; (3) "thumbprinting," which indicates mucosal inflammation (which can also be seen frequently on the abdominal flat plate); and (4) "skip lesions," which suggest areas of inflammation alternating with normal-appearing areas, again suggesting Crohn colitis. Barium can be refluxed into the terminal ileum in many cases, which can assist in the diagnosis of Crohn disease.
  • Small bowel series/small bowel follow-through: The small bowel series, with or without an upper gastrointestinal tract series, provides invaluable information about Crohn disease. This study can reveal if inflammation is present, can assist in the assessment of stricture length and severity, and can help decide the most appropriate surgical approach. Fistulae are often demonstrated on films from a small bowel series, even if they are not suggested based on the clinical evaluation. The small bowel series is usually sufficient for the evaluation of small intestine Crohn disease; rarely, it affords an inadequate view of the terminal ileum and enteroclysis must be performed. Although radiologists may remark on abnormalities suggested in the cecum or ascending colon when the barium from a small bowel series enters the colon, independent confirmation must be sought because the presence of stool and dilution of the barium make proper interpretation of colon findings difficult.
  • Small bowel enteroclysis: The enteroclysis differs from a small bowel series in that a nasoenteric or oroenteric tube is placed and contrast is instilled directly into the small intestine. This is usually performed when fine detail of the intestinal mucosa is required or the distal small intestine is not adequately seen on the small bowel series because the contrast is diluted as it passes through the (usually dilated) small bowel.
  • Computed tomography scan of the abdomen and pelvis: CT scanning of the abdomen and pelvis has limited use in the diagnosis of IBD, but findings may be very suggestive of IBD. Wall thickening on CT scans is nonspecific and may occur from smooth muscle contraction alone, especially in the absence of other extraintestinal inflammatory changes; however, the presence of inflammatory changes significantly increases the predictive value of the CT scan. CT scanning is the ideal study to determine if the patient has abscesses, and it can be used to guide percutaneous drainage of these abscesses. Fistulae also may be detected on CT scans.
  • Fistulogram: Contrast can also be inserted directly into an enterocutaneous fistula in order to help determine the course of the fistula in anticipation of surgical correction and to assist in guiding the surgical approach.

Procedures

  • Colonoscopy
    • This is one of the most valuable tools available to the physician for the diagnosis and treatment of IBD, although its limitations must be recognized. Foremost, not all mucosal inflammation is idiopathic IBD. Infectious causes of inflammation must always be considered, as should diverticulitis and ischemia (which are far more common as new diagnoses in an elderly population than IBD, despite the similar colonoscopic and histologic appearance).
    • When used appropriately, colonoscopy can help determine the extent and severity of colitis, assist in guiding treatment, and provide tissue to assist in the diagnosis. In skilled hands, the colonoscope can frequently reach the terminal ileum and permit assessment of inflammation to assist in the diagnosis or exclusion of Crohn disease. Inflammation may occasionally occur in the terminal ileum in patients with ulcerative colitis; this is referred to as a backwash ileitis and is mild, nonulcerating, and may occur when a widely patent ileocecal valve is present.
    • Be cautious with colonoscopic intervention in patients with IBD. The usual risks of colonoscopy apply (eg, reaction to medication, bleeding, perforation); the risk of bleeding is increased in the presence of inflammation, and even mucosal biopsies may require cautery to limit bleeding. The risk of perforation is also increased, particularly in patients taking high doses of steroids long-term. Also, weigh the risks and benefits of continuing colonic intubation in a patient with IBD who has significant inflammation.
    • Colonoscopy can also be used for therapeutic intervention in patients with IBD. The most common therapeutic use is stricture dilation in persons with Crohn disease; colonic, anastomotic, and even small bowel strictures can often be dilated using pneumatic through-the-scope dilators. Intralesional injection of steroids (eg, triamcinolone at 5 mg in 4 quadrants) may help prevent reformation of the stricture, although this has yet to be demonstrated in controlled trials.
  • Flexible sigmoidoscopy: This study is useful for a preliminary diagnosis in patients with chronic diarrhea or rectal bleeding; however, because of the limited length of the scope (60 cm), it can only help diagnose distal ulcerative colitis or proctitis, but not pancolitis. Rarely, Crohn colitis can be diagnosed based on flexible sigmoidoscopy findings; use caution interpreting sigmoid inflammation, particularly in older patients, because Crohn colitis may be confused with diverticulitis or ischemia.
  • Upper endoscopy: Esophagogastroduodenoscopy is used for the evaluation of upper gastrointestinal tract symptoms, particularly in patients with Crohn disease. Aphthous ulceration occurs in the stomach and duodenum in 5-10% of patients with Crohn disease. The diagnosis of Crohn disease is occasionally made after gastric or duodenal ulcers fail to heal with acid suppression alone.
  • Small bowel enteroscopy: This is of limited use in patients with Crohn disease and is of almost no value in those with ulcerative colitis. Although ulcerations and strictures in the upper half of the jejunum can be demonstrated with enteroscopy, the same information (and often more information) can be demonstrated on the small bowel follow-through x-ray film.
  • Capsule enteroscopy: This technique is performed by having the patient swallow an encapsulated video camera that transmits images to a receiver outside the patient. Most commonly used for finding obscure sources of gastrointestinal blood loss, the images can find ulcerations associated with Crohn disease if upper endoscopy and colonoscopy are unrevealing. Its utility for the diagnosis of Crohn disease is currently under evaluation; the current generation of cameras do not allow for treatment. It must be borne in mind that not all small intestinal ulcerations represent manifestations of Crohn disease. The major risk in patients with Crohn disease is the potential for the camera to become lodged at the point of a stricture, which could require operative intervention for removal.

Histologic Findings

In ulcerative colitis, the inflammation is limited to the mucosa. Inflammation almost always involves the rectum and is contiguous, virtually regardless of the extent of the colon involved. The exception to this rule is that the initial inflammation may appear patchy during colonoscopy performed very early in the ulcerative colitis process, although biopsy specimens of intervening normal-appearing mucosa often do reveal inflammation. The intestinal inflammation of ulcerative colitis only involves the colon; the remainder of the gastrointestinal tract is not inflamed. Biopsy specimens demonstrate neutrophilic infiltrate along with crypt abscesses and crypt distortion. Granulomas do not occur in ulcerative colitis.

The entire intestinal wall is involved with inflammation in Crohn disease, not just the mucosa, as in ulcerative colitis. Biopsy specimens frequently demonstrate granulomas (approximately 50% of the time). The presence of granulomas is often helpful for making the diagnosis but is not necessary.

Because biopsy specimens obtained at colonoscopy are generally superficial mucosal tissue samples, the pathologist often has difficulty making a definitive diagnosis of ulcerative colitis or Crohn disease based on histologic findings alone. However, other causes of inflammation may be suggested based on pathology findings (eg, infectious colitis).

More on Inflammatory Bowel Disease

Overview: Inflammatory Bowel Disease
Differential Diagnoses & Workup: Inflammatory Bowel Disease
Treatment & Medication: Inflammatory Bowel Disease
Follow-up: Inflammatory Bowel Disease
Multimedia: Inflammatory Bowel Disease
References
[ CLOSE WINDOW ]

References

  1. Adachi JD, Rostom A. Metabolic bone disease in adults with inflammatory bowel disease. Inflamm Bowel Dis. Aug 1999;5(3):200-11. [Medline].

  2. American Society for Gastrointestinal Endoscopy. The role of colonoscopy in the management of patients with inflammatory bowel disease. Gastrointest Endosc. Dec 1998;48(6):689-90. [Medline].

  3. American Society for Parenteral and Enteral Nutrition. Intestinal dysfunction/failure: Inflammatory Bowel Disease in: Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. Jul-Aug 1993;17(4 Suppl):18SA-19SA. [Medline].

  4. Andres PG, Friedman LS. Epidemiology and the natural course of inflammatory bowel disease. Gastroenterol Clin North Am. Jun 1999;28(2):255-81, vii. [Medline].

  5. Ardizzone S, Petrillo M, Imbesi V, Cerutti R, Bollani S, Bianchi Porro G. Is maintenance therapy always necessary for patients with ulcerative colitis in remission?. Aliment Pharmacol Ther. Mar 1999;13(3):373-9. [Medline].

  6. Becker JM. Surgical therapy for ulcerative colitis and Crohn's disease. Gastroenterol Clin North Am. Jun 1999;28(2):371-90, viii-ix. [Medline].

  7. Bergman L, Djärv L. A comparative study of loperamide and diphenoxylate in the treatment of chronic diarrhoea caused by intestinal resection. Ann Clin Res. Dec 1981;13(6):402-5. [Medline].

  8. Bernstein CN, Boult IF, Greenberg HM, van der Putten W, Duffy G, Grahame GR. A prospective randomized comparison between small bowel enteroclysis and small bowel follow-through in Crohn's disease. Gastroenterology. Aug 1997;113(2):390-8. [Medline].

  9. Bonner GF, Walczak M, Kitchen L, Bayona M. Tolerance of nonsteroidal antiinflammatory drugs in patients with inflammatory bowel disease. Am J Gastroenterol. Aug 2000;95(8):1946-8. [Medline].

  10. Breuer RI, Soergel KH, Lashner BA, Christ ML, Hanauer SB, Vanagunas A, et al. Short chain fatty acid rectal irrigation for left-sided ulcerative colitis: a randomised, placebo controlled trial. Gut. Apr 1997;40(4):485-91. [Medline].

  11. Brynskov J, Freund L, Rasmussen SN, Lauritsen K, de Muckadell OS, Williams N, et al. A placebo-controlled, double-blind, randomized trial of cyclosporine therapy in active chronic Crohn's disease. N Engl J Med. Sep 28 1989;321(13):845-50. [Medline].

  12. Buchman AL. Bones and Crohn's: problems and solutions. Inflamm Bowel Dis. Aug 1999;5(3):212-27. [Medline].

  13. Burakoff R, Opper F. Pregnancy and nursing. Gastroenterol Clin North Am. Sep 1995;24(3):689-98. [Medline].

  14. Caulfield ME, Michener WM. Ulcerative colitis. In: Wyllie R, Hyams JS, eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. Philadelphia: WB Saunders; 1993:765-87.

  15. Choi PM, Nugent FW, Schoetz DJ Jr, Silverman ML, Haggitt RC. Colonoscopic surveillance reduces mortality from colorectal cancer in ulcerative colitis. Gastroenterology. Aug 1993;105(2):418-24. [Medline].

  16. Colombel JF, Lemann M, Cassagnou M, Bouhnik Y, Duclos B, Dupas JL, et al. A controlled trial comparing ciprofloxacin with mesalazine for the treatment of active Crohn's disease. Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives (GETAID). Am J Gastroenterol. Mar 1999;94(3):674-8. [Medline].

  17. Egan LJ, Sandborn WJ, Tremaine WJ, Leighton JA, Mays DC, Pike MG, et al. A randomized dose-response and pharmacokinetic study of methotrexate for refractory inflammatory Crohn's disease and ulcerative colitis. Aliment Pharmacol Ther. Dec 1999;13(12):1597-604. [Medline].

  18. Ewe K, Press AG, Singe CC, Stufler M, Ueberschaer B, Hommel G, et al. Azathioprine combined with prednisolone or monotherapy with prednisolone in active Crohn's disease. Gastroenterology. Aug 1993;105(2):367-72. [Medline].

  19. Fazio VW, Marchetti F, Church M, Goldblum JR, Lavery C, Hull TL, et al. Effect of resection margins on the recurrence of Crohn's disease in the small bowel. A randomized controlled trial. Ann Surg. Oct 1996;224(4):563-71; discussion 571-3. [Medline].

  20. Felder JB, Korelitz BI, Rajapakse R, Schwarz S, Horatagis AP, Gleim G. Effects of nonsteroidal antiinflammatory drugs on inflammatory bowel disease: a case-control study. Am J Gastroenterol. Aug 2000;95(8):1949-54. [Medline].

  21. Ferry GD. Aminosalicylates in the treatment of children with inflammatory bowel disease. Summary of the workshop on aminosalicylate pharmacology. Inflamm Bowel Dis. May 1998;4(2):113-4; discussion 114-6. [Medline].

  22. Francella A, Dyan A, Bodian C, Rubin P, Chapman M, Present DH. The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study. Gastroenterology. Jan 2003;124(1):9-17. [Medline].

  23. Gaffney PR, Doyle CT, Gaffney A, Hogan J, Hayes DP, Annis P. Paradoxical response to heparin in 10 patients with ulcerative colitis. Am J Gastroenterol. Feb 1995;90(2):220-3. [Medline].

  24. Gendre JP, Mary JY, Florent C, Modigliani R, Colombel JF, Soule JC, et al. Oral mesalamine (Pentasa) as maintenance treatment in Crohn's disease: a multicenter placebo-controlled study. The Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives (GETAID). Gastroenterology. Feb 1993;104(2):435-9. [Medline].

  25. Ginsberg AL. Topical salicylate therapy (4-ASA and 5-ASA enemas). Gastroenterol Clin North Am. Mar 1989;18(1):35-42. [Medline].

  26. Gitnick G, ed. Inflammatory Bowel Disease: Diagnosis and Treatment. New York: Igaku-Shoin Medical; 1995.

  27. Griffiths AM, Ohlsson A, Sherman PM, Sutherland LR. Meta-analysis of enteral nutrition as a primary treatment of active Crohn's disease. Gastroenterology. Apr 1995;108(4):1056-67. [Medline].

  28. Hanauer S, Schwartz J, Robinson M, Roufail W, Arora S, Cello J, et al. Mesalamine capsules for treatment of active ulcerative colitis: results of a controlled trial. Pentasa Study Group. Am J Gastroenterol. Aug 1993;88(8):1188-97. [Medline].

  29. Hanauer SB. Review article: safety of infliximab in clinical trials. Aliment Pharmacol Ther. Sep 1999;13 Suppl 4:16-22; discussion 38. [Medline].

  30. Hanauer SB, Meyers S. Management of Crohn's disease in adults. Am J Gastroenterol. Apr 1997;92(4):559-66. [Medline].

  31. Hurst RD, Cohen RD. The role of laparoscopy and strictureplasty in the management of inflammatory bowel disease. Semin Gastrointest Dis. Jan 2000;11(1):10-7. [Medline].

  32. Hyams JS. Crohn's disease. In: Wyllie R, Hyams JS, eds. Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management. Philadelphia: WB Saunders; 1993:742-64.

  33. International Mesalazine Study Group. Coated oral 5-aminosalicylic acid versus placebo in maintaining remission of inactive Crohn's disease. Aliment Pharmacol Ther. Feb 1990;4(1):55-64. [Medline].

  34. Issenman RM. Bone mineral metabolism in pediatric inflammatory bowel disease. Inflamm Bowel Dis. Aug 1999;5(3):192-9. [Medline].

  35. Jacobsen O, Hojgaard L, Hylander Moller E, Wielandt TO, Thale M, Jarnum S, et al. Effect of enterocoated cholestyramine on bowel habit after ileal resection: a double blind crossover study. Br Med J (Clin Res Ed). May 4 1985;290(6478):1315-8. [Medline].

  36. Katz J. Treatment of Crohn's disease with 5-ASA. Am J Gastroenterol. Sep 1993;88(9):1315-7. [Medline].

  37. Kirschner BS. Ulcerative colitis and Crohn's disease in children. Diagnosis and management. Gastroenterol Clin North Am. Mar 1995;24(1):99-117. [Medline].

  38. Kornbluth A, Present DH, Lichtiger S, Hanauer S. Cyclosporin for severe ulcerative colitis: a user's guide. Am J Gastroenterol. Sep 1997;92(9):1424-8. [Medline].

  39. Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. Feb 1997;92(2):204-11. [Medline].

  40. Kornbluth AA, Salomon P, Sacks HS, Mitty R, Janowitz HD. Meta-analysis of the effectiveness of current drug therapy of ulcerative colitis. J Clin Gastroenterol. Apr 1993;16(3):215-8. [Medline].

  41. Kozarek RA, Patterson DJ, Gelfand MD, Botoman VA, Ball TJ, Wilske KR. Methotrexate induces clinical and histologic remission in patients with refractory inflammatory bowel disease. Ann Intern Med. Mar 1 1989;110(5):353-6. [Medline].

  42. Lamers CB, Griffioen G, van Hogezand RA, Veenendaal RA. Azathioprine: an update on clinical efficacy and safety in inflammatory bowel disease. Scand J Gastroenterol Suppl. 1999;230:111-5. [Medline].

  43. Lewis JD, Schwartz JS, Lichtenstein GR. Azathioprine for maintenance of remission in Crohn's disease: benefits outweigh the risk of lymphoma. Gastroenterology. Jun 2000;118(6):1018-24. [Medline].

  44. Lichtenstein GR. Treatment of fistulizing Crohn's disease. Gastroenterology. Oct 2000;119(4):1132-47. [Medline].

  45. Lichtiger S, Present DH. Preliminary report: cyclosporin in treatment of severe active ulcerative colitis. Lancet. Jul 7 1990;336(8706):16-9. [Medline].

  46. Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med. Jun 30 1994;330(26):1841-5. [Medline].

  47. Lochs H, Mayer M, Fleig WE, Mortensen PB, Bauer P, Genser D, et al. Prophylaxis of postoperative relapse in Crohn's disease with mesalamine: European Cooperative Crohn's Disease Study VI. Gastroenterology. Feb 2000;118(2):264-73. [Medline].

  48. Lofberg R, Danielsson A, Suhr O, Nilsson A, Schioler R, Nyberg A, et al. Oral budesonide versus prednisolone in patients with active extensive and left-sided ulcerative colitis. Gastroenterology. Jun 1996;110(6):1713-8. [Medline].

  49. Mathew CG, Lewis CM. Genetics of inflammatory bowel disease: progress and prospects. Hum Mol Genet. Apr 1 2004;13 Spec No 1:R161-8. [Medline].

  50. Meinzer U, Idestrom M, Alberti C, Peuchmaur M, Belarbi N, Bellaiche M, et al. Ileal involvement is age dependent in pediatric Crohn's disease. Inflamm Bowel Dis. Jul 2005;11(7):639-44. [Medline].

  51. Mekhjian HS, Switz DM, Melnyk CS, Rankin GB, Brooks RK. Clinical features and natural history of Crohn's disease. Gastroenterology. Oct 1979;77(4 Pt 2):898-906. [Medline].

  52. Mesalamine Study Group. An oral preparation of mesalamine as long-term maintenance therapy for ulcerative colitis. A randomized, placebo-controlled trial. Ann Intern Med. Jan 15 1996;124(2):204-11. [Medline].

  53. Michetti P, Peppercorn MA. Medical therapy of specific clinical presentations. Gastroenterol Clin North Am. Jun 1999;28(2):353-70, viii. [Medline].

  54. Munakata A, Yoshida Y, Muto T, Tsuchiya S, Fukushima T, Hiwatashi N, et al. Double-blind comparative study of sulfasalazine and controlled-release mesalazine tablets in the treatment of active ulcerative colitis. J Gastroenterol. Nov 1995;30 Suppl 8:108-11. [Medline].

  55. O'Brien J. Nonsteroidal anti-inflammatory drugs in patients with inflammatory bowel disease. Am J Gastroenterol. Aug 2000;95(8):1859-61. [Medline].

  56. Oostenbrug LE, van Dullemen HM, te Meerman GJ, Jansen PL. IBD and genetics: new developments. Scand J Gastroenterol Suppl. 2003;63-8. [Medline].

  57. Oren R, Moshkowitz M, Odes S, Becker S, Keter D, Pomeranz I, et al. Methotrexate in chronic active Crohn's disease: a double-blind, randomized, Israeli multicenter trial. Am J Gastroenterol. Dec 1997;92(12):2203-9. [Medline].

  58. Poritz LS, Rowe WA, Koltun WA. Remicade does not abolish the need for surgery in fistulizing Crohn's disease. Dis Colon Rectum. Jun 2002;45(6):771-5. [Medline].

  59. Poritz LS, Rowe WA, Swenson BR, Hollenbeak CS, Koltun WA. Intravenous cyclosporine for the treatment of severe steroid refractory ulcerative colitis: what is the cost?. Dis Colon Rectum. Sep 2005;48(9):1685-90. [Medline].

  60. Prantera C, Cottone M, Pallone F, Annese V, Franze A, Cerutti R, et al. Mesalamine in the treatment of mild to moderate active Crohn's ileitis: results of a randomized, multicenter trial. Gastroenterology. Mar 1999;116(3):521-6. [Medline].

  61. Present DH. Review article: the efficacy of infliximab in Crohn's disease--healing of fistulae. Aliment Pharmacol Ther. Sep 1999;13 Suppl 4:23-8; discussion 38. [Medline].

  62. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA, et al. Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med. May 6 1999;340(18):1398-405. [Medline].

  63. Rankin GB, Watts HD, Melnyk CS, Kelley ML Jr. National Cooperative Crohn's Disease Study: extraintestinal manifestations and perianal complications. Gastroenterology. Oct 1979;77(4 Pt 2):914-20. [Medline].

  64. Rowe WA, Bayless TM. Colonic short-chain fatty acids: fuel from the lumen?. Gastroenterology. Jul 1992;103(1):336-8. [Medline].

  65. Rutgeerts P, Feagan BG, Lichtenstein GR, Mayer LF, Schreiber S, Colombel JF, et al. Comparison of scheduled and episodic treatment strategies of infliximab in Crohn's disease. Gastroenterology. Feb 2004;126(2):402-13. [Medline].

  66. Rutgeerts PJ. Review article: efficacy of infliximab in Crohn's disease--induction and maintenance of remission. Aliment Pharmacol Ther. Sep 1999;13 Suppl 4:9-15; discussion 38. [Medline].

  67. Sandborn WJ. Azathioprine: state of the art in inflammatory bowel disease. Scand J Gastroenterol Suppl. 1998;225:92-9. [Medline].

  68. Sandborn WJ, Tremaine WJ, Offord KP, Lawson GM, Petersen BT, Batts KP, et al. Transdermal nicotine for mildly to moderately active ulcerative colitis. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. Mar 1 1997;126(5):364-71. [Medline].

  69. Sands BE, Bank S, Sninsky CA, Robinson M, Katz S, Singleton JW, et al. Preliminary evaluation of safety and activity of recombinant human interleukin 11 in patients with active Crohn's disease. Gastroenterology. Jul 1999;117(1):58-64. [Medline].

  70. Scheppach W. Treatment of distal ulcerative colitis with short-chain fatty acid enemas. A placebo-controlled trial. German-Austrian SCFA Study Group. Dig Dis Sci. Nov 1996;41(11):2254-9. [Medline].

  71. Scheppach W, Sommer H, Kirchner T, Paganelli GM, Bartram P, Christl S, et al. Effect of butyrate enemas on the colonic mucosa in distal ulcerative colitis. Gastroenterology. Jul 1992;103(1):51-6. [Medline].

  72. Scotiniotis I, Rubesin SE, Ginsberg GG. Imaging modalities in inflammatory bowel disease. Gastroenterol Clin North Am. Jun 1999;28(2):391-421, ix. [Medline].

  73. Shaffer EA, Corenblum EB. Osteonecrosis, corticosteroid use and Crohn's disease: evidence-based medicine versus civil law. Can J Gastroenterol. Feb 2000;14(2):91-3. [Medline].

  74. Silvennoinen JA, Karttunen TJ, Niemela SE, Manelius JJ, Lehtola JK. A controlled study of bone mineral density in patients with inflammatory bowel disease. Gut. Jul 1995;37(1):71-6. [Medline].

  75. Stein RB, Hanauer SB. Medical therapy for inflammatory bowel disease. Gastroenterol Clin North Am. Jun 1999;28(2):297-321. [Medline].

  76. Stein RB, Lichtenstein GR. Complications after ileal pouch-anal anastomosis. Semin Gastrointest Dis. Jan 2000;11(1):2-9. [Medline].

  77. Sutherland LR, May GR, Shaffer EA. Sulfasalazine revisited: a meta-analysis of 5-aminosalicylic acid in the treatment of ulcerative colitis. Ann Intern Med. Apr 1 1993;118(7):540-9. [Medline].

  78. Thomsen OO, Cortot A, Jewell D, Wright JP, Winter T, Veloso FT, et al. A comparison of budesonide and mesalamine for active Crohn's disease. International Budesonide-Mesalamine Study Group. N Engl J Med. Aug 6 1998;339(6):370-4. [Medline].

  79. Tremaine WJ. Inflammatory bowel disease workshop. Vail, Colorado, March 22 and 23, 1998. Maintenance therapy in IBD. Inflamm Bowel Dis. Nov 1998;4(4):292-5; discussion 295-301. [Medline].

  80. Yamamoto T, Keighley MR. Smoking and disease recurrence after operation for Crohn's disease. Br J Surg. Apr 2000;87(4):398-404. [Medline].

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Further Reading

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Keywords

IBD, Crohn disease, Crohn's disease, terminal ileitis, granulomatous enteritis, ulcerative colitis, gastrointestinal tract disease, GI tract disease, gastrointestinal disease, GI disease, Clostridium difficile, C difficile, irritable bowel syndrome, IBS, irritable bowel disease, pyoderma gangrenosum, bloody diarrhea, inflamed colon, colonoscopy, proctocolectomy, continent ileostomy, Koch pouch, colonic disease, ileoanal anastomosis, segmental colon resection, colorectal cancer, Crohn colitis, intestinal obstruction, intestinal strictures, scarred strictures, cicatrix strictures, colonic strictures, fistulae, perianal disease, toxic megacolon, colon cancer, pancolitis, perianal abscesses, loss of colonic haustrae, sigmoidoscopy, proctitis, colectomy, occult blood loss, growth retardation, gastric Crohn disease, duodenal Crohn disease, medication-induced arthropathies, axial arthritis, ankylosing spondylitis, sacroiliitis, episcleritis, iritis, uveitis, erythema nodosum, herpetic lesions, calcium oxalate stones, hydronephrosis, sclerosing cholangitis, cholangiocarcinoma, cirrhosis, gallstones, iron deficiency anemia, anemia of chronic disease, strokes, retinal thrombi, pulmonary emboli

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Contributor Information and Disclosures

Author

William A Rowe, MD, Consulting Staff, Gastroenterology, Gastroenterology Associates
William A Rowe, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America
Disclosure: Nothing to disclose.

Medical Editor

Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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